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by Strugglingteens, LLC
Oct 16, 2007
LICENSING AND OTHER IMPORTANT MATTERS
by Larry Stednitz, PhD, IECA
Morro Bay, California
Woodbury Reports Affiliate
Licensing issues have become a major topic of conversations lately. I have watched the debates around licensing for the past couple of years. I watched and listened to the debates and I had trouble taking a position on this issue. I have always thought licensing or some form of accreditation was a basic necessity. From my early days in the field, namely working as the clinical director of Capistrano by the Sea hospital located in Southern California, our reality was that of course you were licensed or accredited by the Joint Commission of Accreditation of Hospitals Organization (JCAHO). On the one hand, I recall the hours and hours of updating our policies and procedures, primarily to assure ourselves that we were in compliance, for out of compliance would mean a huge loss of revenues and our ability to treat patients would end. So due to that real issue, my thoughts were often “well of course a program needs to be licensed.” It is my belief that any program working with teens needs to be licensed by some form of oversight group.
On the other hand, during and after the Woodbury “get together” in North Idaho, I was impressed with many of the attendees and their programs. I could see where this work is fueled by creative and caring people and it is these very people who have introduced many new and exciting approaches. There were people there who have worked with children for decades and from my experience with those who run small programs do so based on their own talents and creativity. Many of them had no license or accreditation because in Montana, there currently are no requirements at this time for licensure. As it turns out, Montana officials have placed the principal of Spring Creek into an important role that could dictate how all programs are licensed in Montana. This role is for the principal to be the chairman of the PAARP board, the body assigned the role of making recommendations to the Montana legislature as to how Montana should license their in-state programs and schools. One suggestion made by this group was to adopt Utah standards for residential treatment programs, placing the smaller programs in a difficult situation. This seems to me to be overkill and perhaps reduce new breakthrough ideas.
I once operated a program in the state of Montana and we were able to become licensed under group home standards through relevant state departments in Montana. Group home standards are extensive in Montana, so those who fear a “lesser” license need not concern themselves. I would like to see some of the smaller programs situated similarly to group home or foster care standards. It is my opinion that programs need to be licensed in order to monitor their own policies and procedures as well as a training and supervision vehicle for their staff. In some instances, new licensure may give the very small programs a distinct disadvantage. I believe that the small programs may find that licensure may be a helpful tool, not an ominous dictate. However, my own experience with Montana license enforcement people is that some see themselves as “cops”, looking for petty ways to harass programs. The department often took the approach that “We know you are doing something wrong, and we will find it!” Hopefully, that mentality is a thing of the past.
There are bigger issues than licensing. I do not believe that those programs that are unlicensed need the licensing so that “big brother” can watch over them. I think more importantly, adhering to their own standards, assists program directors to monitor themselves and to have a tool that will help supervise staff.
Those who refer to smaller programs rely on the known integrity and transparency of the ownership and the people they work with. Licensing at any level, will assist programs to develop a certain routine of predictability in how they handle difficult situations. Standards support staff supervision, training and a certain awareness of the “big picture” of issues that need to be handled consistently. A simple example is that if a program accepts students who are on medications, there needs to be a predictable and consistent manner in which this is handled, as well as a documented history of these medications. There needs to be a routine system in place to search for students who run away from the program. These standards do not need to be complex and unyielding, but all involved need to follow these standards at a very high level. Supervision of staff is the vehicle by which a small or large program train and monitor the progress of staff.
Those who operate programs know the difficulty of managing even a handful of students. The social environment of a program includes a set of rules and standards, consequences for mis-behaviors, and strategies for creating a positive peer influence. Those programs that have developed clear strategies for managing these issues, know that even the best of programs still go through disruptive periods of time and like an orchestra leader, the director and his or her staff lead the entire community through a predictable wave of difficult times, painfully bringing the students and staff back into harmony. This normal disruption is actually a predictable and normal aspect of adolescent treatment. However, this skill is not taught in graduate school, nor is it even discussed. There needs to be an organizational effort to share information and approaches to manage this phenomenon. Supervision of staff is the most important activity a program can undertake and should take place on a consistent weekly schedule. Lessons from the business world can help the process of supervision. First, it is unlikely that one supervisor can effectively manage, inspire, and supervise more than seven employees. This rule is perhaps violated more often than any other basic management strategy. In addition to the ratio of supervisor to supervisee, it is important that supervision takes place formally one hour per week with each employee.
An equally important movement in private schools and programs is the need to complete outcome studies. This would necessarily involve small programs as well as large ones. The bottom line here is what proof do any of the programs have regarding outcomes of their students. I recently read adissertation completed by a colleague. This research indicated that students graduating from a parent choice program showed positive and sustainable progress in psychiatric, psychological, emotional and social issues. On the downside, a large number of students, 37%, continued to use after graduation and saw no problems with substance use. Approximately 40% had also tried a new drug after graduating from the program. This important piece of information has significant ramifications for this and other programs, and that is the need to beef up the substance abuse treatment. The programs of today’s parent choice industry should not make the same mistake hospitals did in the 80’s; neglect to make objective inquiry into the effectiveness of their work. All of us who work in this field today, including this author, have antidotal reports of progress, but under scrutiny, antidotal reports do not hold up.
Treating and educating adolescents is not for the feint of heart! It is serious business and there is room for appropriate licensing that will help all programs take on the significant responsibility of running a program for young people.
October 22, 2007
I agree that further oversight and stricter industry wide standards are a welcome change. However, I am yet to be convinced that the most effective and respected organization to take on this ongoing task and management is the Federal Government, or even the individual States. Logic dictates that without a doubt it is the parents who have the most vested interest in a program's ethics and operations, in the education and treatment of their enrolled students, and the caliber of their family involvement. Their overall collective experience best speaks to a program's honest results and outcome. Parents are the best regulators.
The Schools we work with strongly encourage and promote parent-to-parent communication coupled with an open forum with the Staff. They recognize the importance and necessity for parents to be involved often. Doing so creates transparency and eliminates any shroud of perceived secrecy. Bottom line, our client Schools are regulated by their most important critic: their own customers. Their day-to-day business is out there in front of the parents on their own bulletin board through facility updates, parents posting their experience during/after an on-campus visit, student reports, photos posted by the facility, posts made by the Staff and so forth .
This level of activity, and real-time information sharing, is not possible with a bureaucracy. For a bureaucrat, their concern and interest ends when they clock out. For a parent, it is on-going. It's impossible for any bureaucrat to have the same level of concern as parents do, unless they too had a child in a program. This is why involved, well informed parents offer the greatest credibility and regulation.
Obviously, I am partial to our service and its successes, but I would add that so are the parents who have been able to access these services when needed. Our client Schools go above and beyond what most others offer to their families, based largely on their confidence of how they operate their facility and believe in partnering with their parents.
Since the opening of Core Solutions, we have spoken to a wide range of Schools. Many are interested and really like the idea of further parent involvement. Unfortunately, there are also those who still cling to the fear of having their families more involved, especially through unfiltered communication. I declare that those programs scare me more than any regulation proposed by the State or Federal government. If you're in the family healing field, you need more family involvement, not less.
About Core Solutions:
Core Solutions is known for their successful, affordable private and secure online parent bulletin board service, customized for individual programs, Ed Consultant Groups and other professional organizations.
Please visit www.CoreBB.com to learn more.
Randall Cook, Operations Manager
October 22, 2007
I was just reading your article regarding the oversight of the wilderness programs. Having gone through so many years of oversight by the state licensing boards in Utah and AZ as well as accreditation surveys of JCAHO, I can truly understand your reluctance to license programs. Stifling creativity was most evident in our AZ facility as Office of Behavioral Health Licensure dictated programming, not just life safety codes. It was a constant challenge to adhere to one surveyor's interpretation of what an RTC is supposed to look like while the follow up was by another surveyor, hence different set of expectations.
The problem with state monitored apparatus is that one or two bureaucrats get to dictate (in a vacuum) what should essentially be a clinical art form, an accountable yet creative response to real life state of perpetual crisis!
Having said that, I would advocate for adoption of a standard policy framework, drafted by all providers to include allowances for creativity in programming. Licensing all such programs under a uniform yet stakeholder driven framework can only set the bar. The regulatory body should also act as a resource not just a "gotcha" mechanism.
In AZ there was a program that kept out of the licensing umbrella by running programs only 300 days a year, labeling itself as a school and not a therapeutic program. The same programs gave the entire therapeutic community a black eye with its unprofessional conduct and down right abusive practices.
I agree that such programs are only anomalies and that a majority of wilderness and other experiential treatment programs (I suppose even boot camps) are viable and sound. A stakeholder driven oversight could potentially enhance programs by acting as a resource mechanism. The oversight does not necessarily have to be provided by the state but a conglomeration of treatment providers or a private, independent body, specializing in the specific programming.
8848 Willow Hills Court
Sandy, Utah 84093
October 16, 2007
Dr. Stednitz's words on the value of licensing/accreditation as a "tool" for management are right on target with my own feelings. A JCAHO accreditation is not necessary for us to receive monies from third-party payors, however I have noticed an immense boon to our program after we became accredited over ten years ago. It truly is a tool that helps me monitor and react to things that are important to me and to my clients.
I also wish more programs would follow Dr. Stednitz's recommendation that no one manage more than 7 people. I argue sometimes with other managers who criticize this view as not in harmony with "efficiency", yet I think good management is often not "efficient". A better measure of good management is "effectiveness". Am I able to respond to the varied and individual needs of each of my employees? With an organization of 180 employees, the best way to manage everyone and communicate top-to-bottom has been for us to organize the vast majority of our employees into "teams" of no more than 4-5. Every employee has a meeting with his/her supervisor every week. And every employee has a one-on-one with his/her supervisor at least quarterly.
I was also pleased to read Dr. Stednitz's comments on the "art" of managing the ebbs and flows of sanity among a campus of students and staff. Graduate schools can't teach it because some things can only be learned through experience. The best schools and programs are the ones whose leaders are in tune with, and unified with, their staff. These are the organizations that can respond creatively, quickly, and compassionately to the fluctuations in the tranquility of the community that inevitably occurs in any school that serves teens.
Dustin Tibbitts, LMFTI